Can family support reduce Northern Ireland’s high infant death rates?

Around a long table in an upstairs room in Tullycarnet primary school, a dozen mothers sit crocheting brightly coloured squares of various sizes. Some are heavily pregnant, some already have children: three babies between the ages of seven weeks and one year old are being fed or entertained in the room; more babies and toddlers are downstairs in a small creche, singing along to nursery rhymes with play workers in a soft play corner. Tullycarnet in east Belfast is a deprived area dotted with 1970s council housing blocks. A foreboding anti-drugs mural adorns a four-storey wall next to the doctors surgery, a few steps from the school.

Nikki (not her real name), a young mum with two children, says she enjoys coming to the service with her one-year-old daughter “to get some time to bond together, just us two”. Her older son has cerebral palsy and autism and requires a lot of care. She mentions that she’s been given a voucher through a scheme linked to the service, to buy a supportive mattress to ease the pain her son’s spasms cause him.

East Belfast Family Connections, run with Barnardos in Tullycarnet, is the kind of integrated health and social service Northern Ireland often excels at. As well as emotional support, workers signpost services, liaise with health visitors and doctors on behalf of the women. But despite the concerted efforts to link up all aspects of health, education and social care in Northern Ireland, the infant mortality rate in the country remains among the highest in Europe.

The UK performs poorly on the child mortality rate as a whole: five children (aged between one and 19) a day die in the UK and 1,951 more children die every year than in the best performing country, Sweden. In 2012 more than 3,000 babies died before their first birthday.

But Northern Ireland in particular has a far higher incidence of infant mortality – in 2012, the last year with recorded statistics, there were 106 stillbirths and 90 infant deaths for 24,496 births. The only European countries that have higher rates are Romania and Malta. A recent report, Why Children Die, by the Royal College of Paediatric and Child Health and the National Children’s Board in Northern Ireland offers some insight into why infant deaths remain unnecessarily high, and proposes policy changes to help combat child mortality.

Although some of the reasons for high infant mortality can be put down to the fact that terminations are illegal, even the lack of abortions and higher teen pregnancy rate do not explain why the numbers are so much higher than in the rest of the UK. “Some of our infant mortality can be explained by the fact that we don’t have any terminations, so we have more children born with life-limiting conditions, says Julie-Ann Mahey, a consultant paediatrician in Belfast and one of the authors of the report. “But still poverty is a huge issue in Northern Ireland and crosses all sectarian divides. ”

“More than one in five of our children lives in poverty. That has wide-ranging effects throughout the whole course of a child’s life. So the mothers are much more likely to smoke, have lower birth-weight babies, have pre-term births.” In the last five years household incomes, poverty rates and the labour market have all worsened in Northern Ireland, at far higher rates than the rest of the United Kingdom. Research by the Joseph Rowntree Foundation found that the unemployment rate amongst working-age residents doubled in the five years after the recession, while poverty in 16 to 29-year olds rose eight percentage points to 26%.

Risk factors for infant mortality include maternal smoking, teenage pregnancy and poverty, but these rarely exist in silos, intersecting instead with multiple risk factors that increase in line with deprivation and poverty. Paediatric health experts point out infant deaths can be avoided through reducing incidence of premature birth and low birth weight, risk factors which disproportionately affect the poorest and youngest mothers.

One of the most effective ways of decreasing the risk is through early intervention programmes and targeted support. The East Belfast service runs a “baby club” for new mothers, mixing social support with information workshops on health and parenting, and more intensive outreach in parents’ homes.

Nicola Hannigan, an early years family support worker in the service, visits homes and carries out risk assessments, pointing out potential dangers in homes, providing safety equipment, and checking how the babies are sleeping. One problem area highlighted in the report was the lack of knowledge on safe sleeping: many new parents weren’t clear on potential dangers, from overheating, setting babies down in the wrong position, or sharing beds with babies after a drink or two. “It’s positive help,” Hannigan says. “It’s not all ‘don’t do this’, it’s about trying new things.”

The service helps between 250 and 300 parents at any one time. There is a creche, parenting lessons that culminate in a certificate, one-on-one counselling sessions where parents can ask for advice, or talk about what’s worrying them, and information workshops on nutrition, health and child bonding. “Families don’t come in neat little boxes,” team leader Judith Searle says during a crochet workshop, explaining why the service is so wide-ranging and individual. The hope is to support mothers and families to make positive choices that lower risks for babies from conception onwards. Mothers are usually referred for their first birth, but stay until their children are toddlers, carrying the greater confidence in their parenting capabilities on to future pregnancies. Many don’t have support networks, or close friends with children and can feel isolated.

Northern Ireland also has a medical staff shortage with 672 vacancies remaining unfilled in the health visitor, nursing and midwifery sectors due to a large number of retirements and pinched budgets. This means health visitors are overworked and forced to focus on mothers known to be at risk, leaving many other new mums feeling unsupported.

Smoking during pregnancy remains one of the biggest risks for premature birth and low birth weight. Research in 2012 found 16% of mothers in Northern Ireland smoked during pregnancy compared to 12.7% in England and Wales, with 37% of pregnant women under the age of 20 and 29% of mothers in areas of deprivation continuing to smoke after conception. Early intervention and smoking cessation services for young mothers, especially in areas of high poverty are vital in reducing infant deaths.

Breastfeeding is also an important factor in lowering death rates, especially incidences of sudden infant death syndrome. Despite breastfeeding rates doubling in the past 20 years in Northern Ireland, the rate still remains lower than the rest of the UK. At birth, 64% of mothers in Northern Ireland breastfeed, compared with 81% across the whole of the UK. Partly, this is due to the push to discharge mothers within six hours of giving birth: helping mothers get back home to comfort and privacy has many advantages, but for many women breastfeeding is difficult without some help and guidance.

“If it’s your first baby and you’ve never breastfed, it’s not easy to do. People instinctively think it’s natural and it just happens, but actually it’s hard work,” Mahey explains. “You have to know, you have to be educated, and someone has to help you get it right.” The poorer you are, the less likely you are to breastfeed, and breastfeeding also has a generational factor: if your mother and grandmother breastfed, you are more likely to do so. The social support is crucial in raising breastfeeding rates, and finding a balance between encouraging mothers’ independence and delivering targeted support remains difficult.

“Living in poverty makes things very complicated,” Claire Humphrey, the family centre manager explains. “Everything piles up. Health problems escalate, you miss appointments, and it all gets too much.” One mother who visits the centre has three children under the age of three, one in a wheelchair, the other two in a twin buggy, making it almost impossible for her to leave the house as she can’t afford taxis. The service has seen a notable rise in food poverty, and now distributes three or four food parcels to families who are visibly relieved that they don’t have to choose between paying bills and feeding their children.

The entrenched poverty in Northern Ireland continues to exacerbate the rate of avoidable infant deaths, yet, worryingly, the vast majority of the welfare cuts rolled out across Great Britain have yet to hit Northern Ireland, due to an ongoing deadlock in Stormont. Experts fear forging ahead with cuts and austerity could make the problem worse. “Poverty and continued inequality of access to crucial services across NI means that some children have a much better start in life than others,” says Celine McStravick, director of the National Children’s Bureau NI.

Early help is needed to avert crisis

The fact that more than 3,000 babies die every year is a tragedy. It’s a particularly prevalent problem in Northern Ireland. So it is shocking to realise that more could have been done to tackle well known and avoidable risk factors. A key way of doing this is helping parents earlier before the worst happens.

Making sure new and expectant parents receive help early with issues like safe parenting, maternal health and wellbeing, and housing problems improves their lives and contributes to keeping babies healthy.

This is often best achieved by providing warm and supportive relationships with parents in a welcoming environment, where staff and parents can be honest about risks to babies’ health. Building up support networks is especially important for isolated or young parents who might otherwise struggle to get advice. We need a commitment from national government to act earlier to prevent infant mortality. Waiting until families are already in crisis with issues like child health, parenting and mental health places a heavy toll on them. It is also much more expensive to provide emergency interventions instead of preventative ones.

This is why Action for Children has long advocated for a shift in public spending towards early help. Recently we have been campaigning in partnership with Barnardo’s, the Children’s Society and the NSPCC to put this at the top of the political agenda in the build-up to the general election. Giving every child the best start in life is an imperative for any government. Doing more for families before they reach crisis point would mean that more babies not only survive, but thrive and grow up healthy. Whoever forms the next government needs to commit to this cause.

Kate Mulley is director of policy and campaigns at Action for Children